- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.67 / $115.67 / $240.00
| Professional | | $100.67 | $115.67 | $240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.00 / $661.00 / $1,347.00
| Professional | | $341.00 | $661.00 | $1,347.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $511.50 / $991.50 / $2,020.50
| Professional | 50 | $511.50 | $991.50 | $2,020.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.94 / $230.91 / $513.71
| Professional | | $153.94 | $230.91 | $513.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.52 / $551.65 / $857.49
| Professional | | $305.52 | $551.65 | $857.49 |